Guide to Vestibular Rehabilitation Exercises
The Dizzy Brain: Demystifying Vestibular Exercises
Introduction
Vestibular rehabilitation therapy (VRT) is an exercise-based program designed to promote central nervous system compensation for inner ear deficits. These exercises can help with symptoms such as dizziness, vertigo, visual disturbance, and/or imbalance. This guide outlines common exercise techniques used in vestibular rehabilitation.
Important Safety Notice: Before starting any vestibular rehabilitation program, consult with a healthcare professional. These exercises may temporarily increase symptoms and should be performed in a safe environment.
VOR (Vestibulo-Ocular Reflex) / Gaze Stabilization Exercises
Purpose:
The vestibulo-ocular reflex (VOR) is an automatic mechanism that stabilizes images on the retina during head movement by producing an eye movement that counteracts head movement. When this reflex is impaired due to vestibular disorders, individuals experience visual blurring or "bouncing" vision during head movements (oscillopsia).
VOR exercises aim to:
Improve the brain's ability to use visual signals to compensate for vestibular deficits
Enhance neural plasticity to recalibrate the coordination between eye and head movements
Reduce symptoms of visual blurring, dizziness, and disorientation during daily activities involving head movements
Restore the ability to maintain visual focus while walking, driving, or performing quick head turns
Example: X1 Viewing Exercise
Setup:
Write a letter (X or E) on a card and hold it at eye level (or tape it up on a wall).
Stand in a safe, open area with a plain background.
Execution:
Focus your eyes on the letter.
Move your head side to side (horizontally) while maintaining focus on the letter.
Start with small, slow movements and gradually increase speed as tolerated.
Perform for 1 minute, rest, then repeat.
Progression:
Move head up and down (vertically) while maintaining focus.
Try diagonal head movements.
Increase speed of head movement as symptoms allow.
If you want to learn more in-depth about VOR/Gaze Stabilization Exercises, check out my mini-course:
Visual Motion Sensitivity Exercises
Purpose:
Visual motion sensitivity, also known as visual vertigo or visually-induced dizziness, occurs when excessive reliance on visual input for balance leads to symptoms when exposed to complex or moving visual environments. This condition often develops as a maladaptive response to vestibular disorders.
Visual motion sensitivity exercises aim to:
Desensitize the brain to visually stimulating environments that trigger dizziness
Reduce over-dependence on visual cues for maintaining balance and spatial orientation
Retrain the brain to appropriately integrate visual information with vestibular and proprioceptive inputs
Enable individuals to comfortably navigate challenging visual environments such as grocery stores, shopping malls, busy streets, and crowds
Decrease anxiety and avoidance behaviors associated with visually complex situations
These exercises are especially helpful for individuals who report increased dizziness in environments with repetitive visual patterns, scrolling computer screens, busy visual backgrounds, or when watching moving objects.
Example: Optokinetic Training Exercise
Setup:
Find a video of vertical/horizontal stripes moving across a screen (available online or through apps).
Alternatively, you can create your own by attaching paper with stripes to a rotating object.
Execution:
Sit comfortably and watch the moving stripes for 30 seconds.
Take a break if symptoms become moderate to severe.
Gradually increase viewing time as tolerance improves.
Progression:
Increase duration of exposure.
Add slow head movements while watching.
Try different directions of stripe movement (horizontal, vertical, diagonal).
If you want to learn more in-depth about Visual Motion Sensitivity Exercises, check out my mini-course:
Habituation Exercises
Purpose:
Habituation is a form of neural adaptation where repeated exposure to a stimulus reduces the response to that stimulus over time. In vestibular rehabilitation, habituation exercises are based on the principle that controlled, repeated exposure to movements or positions that provoke mild symptoms will eventually lead to symptom reduction.
Habituation exercises aim to:
Decrease the brain's sensitivity to specific movements that trigger dizziness or vertigo
Retrain the central nervous system to recognize certain movements as normal rather than threatening
Reduce the intensity and duration of motion-provoked symptoms through systematic desensitization
Break the cycle of movement avoidance that often leads to deconditioning and increased sensitivity
These exercises are particularly effective for individuals with motion-provoked dizziness, certain types of persistent postural-perceptual dizziness (PPPD), and those with residual dizziness after BPPV treatment or other vestibular insults. The key principle is identifying the specific movements that provoke mild to moderate symptoms and systematically practicing these movements to induce central nervous system adaptation.
Example: Movement Habituation Exercise
Setup:
Identify movements that trigger mild symptoms (e.g., bending forward, looking up).
Ensure you have a safe environment with support nearby.
Execution:
Perform the triggering movement slowly and controlled.
Hold briefly at the end position.
Return to starting position and rest until symptoms decrease.
Repeat the movement 5-10 times, twice daily.
Progression:
Increase speed of movements.
Combine movements (e.g., bending and turning).
Perform in more challenging environments.
Balance Exercises
Purpose:
Balance is maintained through the complex integration of input from three sensory systems: vestibular (inner ear), visual, and somatosensory (touch and proprioception). When the vestibular system is compromised, the brain must learn to rely more heavily on the remaining systems or develop new strategies for maintaining equilibrium.
Balance exercises aim to:
Improve postural stability during both static (standing) and dynamic (moving) activities
Reduce fall risk by enhancing the body's ability to maintain center of gravity within the base of support
Strengthen the use of remaining sensory inputs (visual and proprioceptive) to compensate for vestibular deficits
Develop new motor patterns and automatic postural responses when balance is challenged
These exercises are beneficial for almost all vestibular patients but are especially important for older adults with vestibular disorders, individuals with bilateral vestibular loss, and those with a history of falls or near-falls. They address both the physical limitations caused by vestibular dysfunction and the psychological components of balance confidence.
Example: Progressive Standing Balance Exercise
Setup:
Stand near a counter or sturdy chair for support if needed.
Start on a firm surface.
Execution:
Stand with feet together for 30 seconds.
Progress to semi-tandem stance (one foot slightly ahead of the other).
Progress to tandem stance (heel-to-toe position).
Try standing on one leg.
Perform each position for 30 seconds, rest, then repeat.
Progression:
Close eyes (only if safe to do so).
Stand on a foam pad or cushion.
Combine challenges (e.g., tandem stance on foam with eyes closed).
BPPV Treatment Maneuvers
Purpose:
Benign Paroxysmal Positional Vertigo (BPPV) is the most common vestibular disorder, caused by otoconia (calcium carbonate crystals) that have become dislodged from the utricle and migrated into one of the semicircular canals, most commonly the posterior canal. When the head moves in certain positions, these misplaced crystals create abnormal fluid movement that sends false signals about head position and rotation to the brain.
BPPV treatment maneuvers aim to:
Relocate displaced otoconia from the affected semicircular canal back to the utricle where they can be reabsorbed and no longer cause symptoms
Address the underlying mechanical cause of vertigo
Provide immediate relief of positional vertigo in many cases (success rates of 80-90% for posterior canal BPPV with appropriate maneuvers)
Prevent long-term complications such as falls, anxiety, and activity restrictions related to untreated BPPV
These repositioning maneuvers are specifically designed for BPPV and work differently than other vestibular exercises. Rather than promoting adaptation or habituation, they physically move the displaced crystals through the semicircular canals using gravity, with each position in the sequence designed to move the particles progressively toward the utricle.
Important Note: BPPV maneuvers should ideally be performed under the guidance of a healthcare professional who can determine which ear and canal is affected. Incorrect diagnosis or treatment can worsen symptoms.
Example: Modified Epley Maneuver (for posterior canal BPPV)
Setup:
Sit on a bed with your head turned 45 degrees toward the affected ear.
Have a pillow positioned behind you.
Execution:
Quickly lie back with your head still turned, neck extended over the pillow. If symptoms appear, wait for them to subside. Hold for an additional 30 seconds.
Without raising your head, turn it 90 degrees to the opposite side. Hold for 30 seconds.
Roll your body to the side in the same direction your head is facing, looking toward the floor. Hold for 30 seconds.
Slowly sit up on that side.
After the maneuver:
Avoid quick and excessive head and body movement for the rest of the day.
Sleep with your head slightly elevated for only the next night.
General Guidelines for All Exercises
Safety First:
Have something stable to hold onto nearby.
Remove tripping hazards from your exercise area.
Consider having someone present during initial sessions.
Symptom Management:
Expect some increase in symptoms during exercises.
Use the "traffic light" system:
Green: Mild symptoms - continue exercises.
Yellow: Moderate symptoms - slow down but continue.
Red: Severe symptoms - stop and rest.
Progression:
Begin with exercises that produce mild symptoms.
Progress gradually - don't rush to more difficult levels.
Consistency is key - perform exercises daily as prescribed.
Track Your Progress:
Keep a diary of exercises performed and symptom levels.
Note improvements in daily activities and symptom triggers.
Seek Professional Guidance:
These exercises work best when tailored to your specific condition.
Regular follow-up with healthcare providers ensures appropriate progression.
When to Contact a Healthcare Professional
Seek medical attention if you experience:
Severe, persistent vertigo or dizziness
New or different symptoms during exercise
Hearing loss, fullness, or ringing in the ears
Severe headaches, especially with vision changes
Falls or near-falls
No improvement after 4-6 weeks of consistent exercise
Disclaimer: This guide is for educational purposes only and is not intended to replace professional medical advice. Always consult with a healthcare provider before beginning any exercise program.